Int J Gastrointest Interv 2022; 11(4): 160-167
Published online October 31, 2022 https://doi.org/10.18528/ijgii220051
Copyright © International Journal of Gastrointestinal Intervention.
Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
Correspondence to:*Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan.
E-mail address: firstname.lastname@example.org (N. Okuno).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Endoscopic ultrasound (EUS)-guided interventions, including EUS-guided biliary drainage and EUS-guided cystic drainage, are now well developed and in widespread use. Intraperitoneal abscess requires drainage because mortality associated with an undrained abscess is high. Percutaneous or surgical drainage has traditionally been performed, but there have been numerous reports of EUS-guided drainage for intraperitoneal abscesses in recent years. EUS-guided abscess drainage has the advantage of being less invasive and enabling direct access to the cavity via the trans-luminal route as well as clear visualization of interposed vessels using color Doppler ultrasonography. It is necessary to consider the advantages and disadvantages when selecting a drainage method. This article reviews the current status of EUS-guided abscess drainage at three sites: the liver, pelvis, and mediastinum.
Keywords: Abscess, Drainage, Endosonography
The undrained abdominal abscess is associated with a high degree of mortality.1 Traditionally, abdominal and pelvic abscesses have been drained by percutaneous techniques or surgically. Of these, percutaneous drainage is usually recommended as the first-line treatment as it is minimally invasive and requires a shorter duration of hospitalization compared to surgery.2 Theoretically, endoscopic ultrasound (EUS)-guided abscess drainage has the same advantages as percutaneous drainage and also eliminates the need for an external drain. EUS-guided drainage has recently become the standard treatment for peripancreatic fluid collection;3 however, few studies have evaluated its efficacy for drainage of non-peripancreatic fluid collections. Here, we review the current status of EUS-guided abscess drainage at three sites: the liver, pelvis, and mediastinum.
Liver abscesses occur most commonly in elderly patients and are associated with malignant biliary obstruction, biliary disease, hepatic trauma, bacteremia, and amebiasis. Most are drained percutaneously, although 14 case reports and three retrospective studies have been published regarding EUS-guided drainage (Table 1).4–20 In these previous reports, the most common indication for EUS-guided liver abscess drainage was failed medical therapy and inability to drain the abscess percutaneously. Seewald et al4 first described EUS-guided liver abscess drainage in 2005, reporting that the entire left lobe and most of the central segments of the liver were well visualized and accessible using this technique. Compared with the percutaneous transhepatic approach, EUS-guided drainage has several advantages: (1) direct access to the cavity in the left lobe of the liver via the trans-gastric route, (2) clear visualization of interposed vessels using color Doppler ultrasonography, and (3) avoidance of transcutaneous infection. EUS-guided drainage of liver abscess appears safe in selected patients in whom a trans-gastric approach can be used to minimize the distance between the abscess and the ultrasound transducer. In most reports, the abscess was located in the left lobe or the caudate lobe, but it is not possible to visualize and access all liver segments by EUS. The right lobe should be visualized from the duodenum, as the long and rigid tips of EUS preclude maneuverability. However, right lobe drainage can be challenging using EUS. Yamamoto et al16 reported the usefulness of EUS-guided liver drainage for an abscess in the right lobe in which percutaneous drainage was difficult due to Chilaiditi syndrome. Although there are fewer reports of drainage in the right lobe than the left lobe, these have been considered successful.14–17
Table 1 . Summary of Literature on Endoscopic Ultrasound-Guided Liver Abscess Drainage.
|Author (year)||Abscesses (||Location||Approach||Drainage method||Technical success (%)||Clinical success (%)||Adverse events|
|Seewald et al (2005)4||1||Left lobe||TG||7 Fr NDT||100||100||None|
|Ang et al (2009)5||1||Left lobe||TG||10 Fr, 8 Fr PS||100||100||None|
|Noh et al (2010)6||3||Caudate lobe (2)|
Gastrohepatic space (1)
|7 Fr PS|
7 Fr NDT
|Itoi et al (2011)7||2||Caudate lobe|
|7 Fr PS|
5 Fr NDT
|Keohane et al (2011)8||2||Caudate lobe||TG||7 Fr, 10 Fr PS||100||100||None|
|Medrado et al (2013)9||1||Left lobe||TG||10 mm PCSEMS||100||100||Intra-abscess stent migration|
|Alcaide et al (2013)10||1||Left lobe||TG||10 mm LAMS, PS||100||100||None|
|Kawakami et al (2014)11||1||Left lobe||TG||16 mm dedicated wide FCSEMS||100||100||None|
|Koizumi et al (2015)12||1||Left lobe||TG||5 Fr NDT||100||100||None|
|Kodama et al (2015)13||1||Left lobe||TG||7 Fr PS, 6 Fr NDT → 10 mm FCSEMS||100||100||None|
|Tonozuka et al (2015)14||7||Left lobe (6)|
Right lobe (1)
|16 mm dedicated wide FCSEMS or 8–10 mm FCSEMS, 5 Fr or 6 Fr NDT||100||71.4||None|
|Ogura et al (2016)15||8||Left lobe (6)|
Right lobe (2)
|10 mm FCSEMS, 7 Fr PS||100||100||None|
|Yamamoto et al (2017)16||1||Right lobe||TD||5 Fr NDT||100||100||None|
|Carbajo et al (2019)17||9||Left lobe (4)|
Right lobe (5)
|Venkatesh et al (2020)18||1||Caudate lobe||TG||7 Fr PS (2)||100||100||None|
|Chandra and Chandra (2021)19||3||Caudate lobe (1)|
Left lobe (2)
|TG||8 Fr PS|
8–10 Fr NDT
|Molinario et al (2021)20||1||Left lobe||TG||20 mm LAMS, 8.5 Fr PS||100||100||None|
The procedure for EUS-guided liver abscess drainage is the same as that for peripancreatic fluid collection. The liver abscess is visualized using a convex echoendoscope. The left lobe and the caudate lobe are visualized from the stomach, and the right lobe is visualized mainly from the duodenum. After the liver abscess is identified, it is punctured with a needle. The first reported case by Seewald et al4 used a 22G needle, but a 19G needle has been used in most other cases. A guidewire is coiled within the liver abscess and tract dilation is performed. Mechanical dilators and balloon dilators are mainly used for dilation. Electric cautery has been used in placement of a lumen-apposing metal stent (LAMS) or dedicated wide fully covered self-expanding metal stent (FCSEMS).10,11,14,17 After tract dilation, stent placement is performed. Table 1 lists the stents used in previous reports. Until 2011, there were reports only of a plastic stent and nasocystic tube use. In 2013, Medrado et al9 reported using a partially covered self-expanding metal stent (PCSEMS). The combination of a pigtail plastic stent and FCSEMS became the drainage system used by most endoscopists. Recent studies have reported insertion of an FCSEMS. The review by Chin and Asokkumar21 stated that FCSEMSs have several advantages compared to plastic stents: (1) more rapid drainage due to the wider diameter of the metal stent, (2) minimized risk of pus leakage, (3) enhanced ability to remove solid necrotic debris, and (4) fewer repeated procedures. Although these theoretical advantages over plastic stents remain unvalidated, the review included a variety of stents and high levels of technical and clinical success were found in all cases.
There are no reports of difficulty with the drainage technique; however, large abscesses and the presence of solid components may require additional endoscopic drainage. Tonozuka et al14 reported a clinical success rate of 71.4% at the first session. In two patients with large abscesses and solid components, resolution was achieved after the second session. Direct endoscopic necrosectomy was required in one case, and the final clinical success rate was 100%. Few adverse events and no fatalities have been associated with EUS-guided liver abscess drainage. Medrado et al9 reported a case of intra-abscess stent migration in which trans-gastric drainage was performed using a 60 mm × 10 mm PCSEMS, with no adverse events. At 2 weeks after the procedure, EUS revealed a reduction in the size of the liver abscess and intra-abscess stent migration. A 10-Fr double pigtail stent was inserted inside the SEMS to maintain the drainage channel, and there was full clinical resolution by 8 weeks. Carbajo et al17 reported three cases of gastrointestinal bleeding that were managed conservatively and one perforation that was closed during the procedure. However, as this report included other upper abdominal abscesses, it was unclear whether adverse events had occurred in the patients with liver abscesses. Tonozuka et al14 reported spontaneous migration of an FCSEMS into the digestive tract without any adverse events. Stent migration is a limitation of FCSEMSs, although the most recent LAMSs have an anti-migratory system to prevent its occurrence. The main problem is internal stent migration, and there is no clinical problem with stent dislocation after fistula formation and clinical resolution of the abscess. Stent removal, when necessary, was performed without difficulty after resolution of the abscess.
Pelvic abscess is a relatively common complication of obstetric and colorectal surgery. And can also occur in Crohn’s disease and diverticulitis. The management of pelvic abscess can be technically challenging due to anatomical considerations. Traditionally, pelvic abscess is treated by surgery or percutaneous drainage. Numerous other therapeutic modalities have been described, including transrectal, transvaginal, and transgluteal drainage.22–24 Table 2 summarizes the literature on EUS-guided pelvic drainage,25–36 for which reports are much more numerous compared with other areas such as the liver and mediastinum.
Table 2 . Summary of Literature on Endoscopic Ultrasound-Guided Pelvic Drainage.
|Author (year)||Abscesses (||Approach||Drainage method||Technical success (%)||Clinical success (%)||Adverse events|
|Giovannini et al (2003)25||9||TR||8.5 Fr/10 Fr PS||100||88.8||Abdominal pain (1)|
|Attwell et al (2003)26||1||TS||Two 5 Fr PS||100||100||Fever|
|Varadarajulu and Drelichman (2007)27||4||TR/TS||10 Fr drain||100||75||None|
|Trevino et al (2008)28||4||TR||7 Fr PS and 10 Fr drain||100||100||None|
|Varadarajulu and Drelichman (2009)29||25||TR/TS||7 Fr PS in 25, plus 10 Fr drain in 10||100||96||None|
|Ramesh et al (2013)30||38||TR (27)|
|PS ± drain||TR/TC|
|Hadithi and Bruno (2014)31||8||TR (6)|
|One or two|
7 Fr PS
|Ratone et al (2016)32||7||TR||Two 7 Fr PS||100||100||None|
|Javed and Ho (2016)33||1||TR||LAMS||100||100||None|
|Poincloux et al (2017)34||37||TR (34)|
|Aspiration only in 4, one or more PS in 29, LAMS in 4||100||91.9||Perforation (1)|
Stent migration (1)
Rectal discomfort (1)
|Mudireddy et al (2018)35||8||TR||LAMS||100||87.5||Details unknown|
|Donatelli et al (2021)36||7||TR||LAMS||85.7||85.7||None|
Giovannini et al25 first described EUS-guided drainage and aspiration of pelvic abscesses in 2003. They reported successful transrectal stent insertion into the fluid collection in nine patients, among whom complete drainage was achieved without relapse in eight and surgical drainage was performed in one who had incomplete drainage. In three patients, only aspiration was possible; of these, two developed recurrence of the abscess and required surgical treatment. Attwell et al26 described EUS-guided drainage for diverticular abscess as a bridge to surgery. Varadarajulu and Drelichman27 reported that transrectal stents can clog easily, particularly with fecal matter or pus, and when left long term can cause perirectal pain, migrate spontaneously, or cause retrograde infection. In 2007, they reported the usefulness of EUS-guided pelvic drainage using a drainage catheter. A combined technique using an EUS-guided transrectal drainage catheter and a transmural pigtail stent placement was adopted in 2008.28 A short-term (36–48 hours) drainage catheter provided access for continued abscess irrigation, and a medium-term (2 weeks) stent maintained a patent transmural tract to ensure abscess resolution. Abscesses were resolved in all four patients. The efficacy of this combined approach was prospectively validated in a cohort of 25 patients.29 The procedures were technically successful in all patients, the treatment success rate was 96%, and there were no adverse events. The combined technique minimizes the possibility of accidental dislocation of the drainage catheter and enables continuous irrigation, and has the additional advantages of minimizing patient discomfort and facilitating quick discharge of patients from hospital after removal of the drainage catheter. The 2013 study by Ramesh et al30 found no difference between transcolonic and transrectal drainage in terms of rates of technical success, clinical success, or adverse events. When evaluated by etiology, treatment success was significantly lower for diverticular abscess compared with others (25% vs 97%;
In this way, EUS-guided pelvic drainage has been performed by various and nonstandardized methods, such as needle aspiration, aspiration with or without tract dilation, and placement of plastic and/or LAMS. Double pigtail plastic stents were used in all cases. It is recommended that double pigtail plastic stents be as short as possible, particularly if drainage is done in the lower rectum, because of the risk of discomfort if the stent touches the anal canal.32,34 The risk of leakage must also be considered when using plastic stents. Recent reports suggest that LAMS placement is advantageous in terms of preventing leaks and discomfort.33–37 Of four patients treated with LAMS in the study by Poincloux et al,34 one developed recurrence and one with diverticular abscess had a perforation. EUS-guided pelvic drainage offers a viable alternative that can minimize the need for surgical intervention. It is noteworthy that higher complication rates have been reported for abscesses with diverticular etiology.30 There are no reports of tubular FCSEMS for EUS-guided pelvic drainage. When performing EUS-guided pelvic drainage, it is necessary to consider the etiology when selecting an appropriate drainage method.
Our case is shown in Fig. 4–6. A patient with terminal pancreatic cancer developed a pelvic abscess that showed no clinical improvement with antibiotic therapy. EUS-guided transrectal drainage was performed. The stents were retained and after infection control, the patient was able to spend remaining time at home.
Mediastinal abscesses with uncontrolled infection can be fatal. Surgery has been used as the first-line treatment, but there have been many reports over the years of the diagnostic usefulness of EUS-guided fine needle aspiration via the transesophageal approach for mediastinal lesions.38–40 However, there are still few reports regarding the usefulness of EUS-guided mediastinal drainage: only seven case reports and one prospective study (Table 3).41–47 Fritscher-Ravens et al48 first reported the successful aspiration of a mediastinal abscess using EUS in 2000, and Kahaleh et al41 first reported EUS-guided mediastinal drainage using a 7-Fr single pigtail stent in 2004. In 2005, Wehrmann et al42 reported endoscopic debridement of para-esophageal and mediastinal abscesses in a prospective case series of 20 patients. Simple drainage with an 8.5-Fr double pigtail stent was sufficient in 4 cases, puncture was impossible in 1 case, and debridement was performed after drainage in the remaining 15. In this report, both EUS-guided and endoscopic approaches were used for drainage, but no further breakdown of other details was provided. The clinical success rate was 100%, but one patient died from a massive pulmonary embolism one day after successful debridement. No other adverse events were observed. In all other case reports, treatment was by EUS-guided drainage only. Use of a pigtail plastic stent has been described in four reports,37,41,43,45 and use of a nasobiliary drainage tube (NDT) in two.44,47 Shibuya et al47 reported several advantages of external drainage with EUS-guided mediastinal drainage. First, irrigation with saline followed by drainage enables complete cleansing of the abscess cavity, and drainage failure can be prevented by changing the position of the tube and the patient’s body. Second, culture samples can be taken repeatedly. Third, pharyngeal discomfort is less likely to occur with external drainage than with internal drainage. Fourth, it is easy to perform external drainage without substantial technical skill even in narrow working spaces, such as very close to the upper esophageal sphincter. In addition, an oral elemental diet can be ingested with monitoring via the NDT. However, external drainage using NDT is limited by the diameter of the drainage route. The limitation in diameter can lead to treatment failure through disruption of necrotic tissue. Consiglieri et al46 reported the usefulness of 10-mm LAMS. Balloons and tapered dilators are the main devices used for dilation, and there are no reports of electric cautery for EUS-guided mediastinal drainage. Two case reports, including one from our institution, have described a transgastric approach to the mediastinum.37,45 High technical and clinical success rates were reported in all cases, although Piraka et al43 reported pneumothorax and mediastinitis in one patient who underwent drainage alone. In addition, pneumoderma, mediastinal emphysema, and bilateral pneumothorax developed in one of our patients who underwent transesophageal EUS-guided rendezvous.49 Although this is a different case to abscess drainage, when performing EUS-guided mediastinal drainage it is important to confirm that the abscess is firmly encapsulated and separated from the pleural cavity. There are few reports of EUS-guided mediastinal drainage, and it is necessary to consider the advantages and disadvantages when selecting a drainage method.
Table 3 . Summary of Literature on Endoscopic Ultrasound-Guided Mediastinal Drainage.
|Author (year)||Abscesses (||Approach||Drainage method||Technical success (%)||Clinical success (%)||Adverse events|
|Kahaleh et al (2004)41||1||TE||7 Fr PS (single pigtail)||100||100||None|
|Wehrmann et al (2005)42||20||TE||8.5 Fr PS alone in 4, plus debridement in 15||95||100||Pulmonary embolism (1)|
|Piraka et al (2009)43||2||TE||Two 10 Fr PS (double pigtail)||100||100||Pneumothorax (1)|
|Mahady et al (2011)44||1||TE||7 Fr NDT||100||100||None|
|Saxena et al (2014)45||1||TG||Two 7 Fr PS (double pigtail)||100||100||None|
|Consiglieri et al (2015)46||1||TE||10 mm LAMS||100||100||None|
|Shibuya et al (2019)47||1||TE||6 Fr NDT||100||100||None|
|Aritake et al (2021)37||1||TG||Three 7 Fr PS (double pigtail)||100||100||None|
Our case is shown in Fig. 7–9. A patient with esophageal cancer developed a mediastinal abscess following perforation of the esophagus. There was no clinical improvement with antibiotic therapy, and EUS-guided transesophageal mediastinal drainage was considered as a bridge to surgery. Surgery was performed after infection control.
We have reviewed the current status of EUS-guided abscess drainage. Although there are no comparative studies with percutaneous drainage or surgery, EUS-guided abscess drainage has high clinical and technical success rates without serious adverse events. It is necessary to consider the advantages and disadvantages when selecting a drainage method.
Dr. Mizuno reports the following grants, none of which are connected with the submitted work: grants from Yakult Honsha, AstraZeneca, Novartis, MSD, ASLAN Pharmaceuticals, Incyte, Ono Pharmaceuticals, Seagen, Taiho Pharmaceutical and Eisai; personal fees from Yakult Honsha, AstraZeneca, Novartis, FUJIFILM Toyama Chemical and MSD.
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